Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. Be SureToSignTheApplication. <br /> FOR QFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> � <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cout Or inance o. 186 and the rules and regulations of the San Joaq in L ca Health District. <br /> Exact Site Address0 �Pnii City/Towne <br /> Owner's Name Phone �u <br /> Address City <br /> Contractor's Name Lic nse# 5V Sl i6 Business Phone q' 7 7E) <br /> Contractor's Addressee SI L� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1>1�111 � No <br /> TYPE OF WORK (CHECK): NEW WELL�ff— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR 11 0 <br /> REPLACEMENT❑ y� S <br /> DISTANCE TO NEAREST: Septic Tank /�V Sewer Lines Pit Privy <br /> i <br /> Sewage Disposal Fielp Cesspool/Seepage Pit Or& Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ABLE TOOL_ Dia. of Well Excavation r r -- <br /> �r. <br /> DOMESTIC/PRIVATE 11 DRILLED - .. Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .— <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information � ~ <br /> ❑ GEOPHYSICAL Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ■ <br /> '1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County F <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca for a Grout Inspection prior to grouting and a final inspection. ` <br /> Signed X f)AAA �QTitle: Date: - <br /> (Draw Plot Plan on Reverse Side) <br /> =137TMNT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments:, <br /> Phase i Grout Inspection Phas III Fina! Inspection// <br /> Inspection By- � �Q1l.CNY`- ate —G� 0 Inspection By + ' Date <br /> ..00-0 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE cA <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 57t-+ <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />